Reflections on Pulse Oximetry Screening for CCHD.

Abstract

The idea of using pulse oximetry to screen for critical congenital heart disease (CCHD) began >20 years ago.1 The concept, which is simple in principle, took a laborious path from curious possibility to national standard.Much of the delay in implementing this screening process related to anxiety about the impact of false-positive tests and the burden on the health care system. Thankfully, since the broader acceptance of this screening approach, much of the anxiety has been allayed through our increased understanding of the logistics of pulse oximetry screening.In this issue of Pediatrics, Schwartz et al describe their experience at a large community hospital over 8 years.2 It should be noted that this hospital and this clinical team were instrumental in moving the pulse oximetry screening model forward. It is exciting to see this longer-term experience.The results described by Schwartz et al are largely reassuring. The positive predictive value for screening was 39% for CCHD. Over an 8-year period, only 31 out of almost 65 000 newborns failed the pulse oximetry screening. When the concept of universal pulse oximetry screening was first proposed, there were concerns that a high proportion of newborns would require detailed and expensive cardiology screening with echocardiography and, potentially, additional consultation. But, as Schwartz and others have shown, this turns out not to be the case. Most centers have been able to implement the pulse oximetry screening in an efficient manner incorporated into the routine care of newborns. Although there is admittedly substantial amount of work to screen 65 000 newborns only to uncover 12 children with critical congenital heart disease, such early detection can certainly be lifesaving. The yield is higher than many other newborn screens that have been endorsed by national organizations.3At this point, the pulse oximetry screening paradigm has largely been embraced. There had been some hope that, over time, prenatal detection might continue to increase such that the need for pulse oximetry screening would be unnecessary. However, the trends in prenatal diagnosis improvement seem to have plateaued. Therefore, for the foreseeable future, pulse oximetry–based CCHD screening in the newborns will continue to have an important role.Several investigators have shown that pulse oximetry screening for CCHD is cost-effective and lifesaving.4 The work by Schwartz et al has helped catalyze this national effort to advance pulse oximetry screening. This new critical appraisal of their experience over 8 years helps to provide context and further refinement to the pulse oximetry screening model. Their work, and that of others, has suggested refinements to this screening paradigm to minimize work but still achieve a high yield but low false-negative rate.5 Schwartz et al and the other pioneers in this arena deserve to be congratulated. Children with CCHD are alive today and thriving because of pulse oximetry–based screening. We can celebrate a successful paradigm of public health, clinician, and most importantly, patient and family collaboration to reduce unnecessary deaths from missed CCHD.